Prior Authorization Appeals Specialist

🔥 3 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 10%

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IVX Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2013

🏥 Healthcare

💊 Pharmaceuticals

👥 B2C

Healthcare • Pharmaceuticals • B2C

IVX Health is a national network of outpatient infusion centers that provides biologic infusion and injection therapies for patients with complex chronic conditions such as Crohn’s disease, multiple sclerosis, rheumatoid arthritis, psoriasis, lupus, and severe asthma. The company emphasizes patient comfort and convenience with private suites, flexible scheduling including evenings and weekends, in-network insurance options, and high-quality care delivered by ARNPs, RNs, and medical directors across multiple U. S. locations.

📋 Description

• Review pre-service authorization denials, determine next steps, and coordinate reconsiderations, appeals, peer-to-peer reviews, and payer exception requests within applicable timeframes. • Interpret payer policies, medical necessity criteria, utilization management requirements, coverage guidelines, and denial rationales. • Partner with providers and internal teams to obtain letters of medical necessity, clinical notes, supporting records, and other documentation. • Monitor denial and appeal inventory, conduct follow-up, escalate complex cases and payer barriers, and support challenging authorization issues. • Communicate denial outcomes, documentation requirements, and escalation options with providers, market teams, Prior Authorization, Sales, Operations, Contracting, and leadership. • Identify denial trends and payer barriers and improve workflows to reduce preventable denials and strengthen authorization accuracy. • Develop and maintain workflows, SOPs, playbooks, and training materials; support onboarding, training, and knowledge sharing. • Maintain productivity, responsiveness, data security, and communication while working remotely and following IVX Health policies.

🎯 Requirements

• High school diploma or equivalent required; Associate's or Bachelor's degree preferred. • 3–5 years of experience in prior authorization, reimbursement, denial management, appeals, or infusion healthcare required. • Demonstrated experience managing complex authorization or denial-related cases across multiple payer types. • Experience working with commercial and government payers, including Medicare and Medicaid. • Advanced understanding of prior authorization, medical necessity, denial, reconsideration, and appeals processes. • Ability to interpret and apply payer policies and coverage requirements across complex and non-standard scenarios. • Strong analytical, problem-solving, and critical-thinking skills with exceptional attention to detail and accuracy. • Strong written and verbal communication skills with the ability to effectively collaborate with providers, payers, and internal stakeholders in a remote environment. • Ability to manage a high-volume workload while prioritizing complex and escalated cases. • Proficiency with EMR systems, payer portals, and Microsoft Office applications. • Ability to train, mentor, and serve as a knowledgeable resource to peers. • Strong understanding of commercial and government payer requirements, including Medicare and Medicaid.

🏖️ Benefits

• Medical, Dental, and Vision Coverage • Prescription Drug Coverage and Telemedicine Services • Health Savings Account (HSA), Health Reimbursement Arrangement (HRA), and Flexible Spending Options • 401(k) Retirement Plan with Company Match • Life, AD&D, and Disability Insurance • Accident, Critical Illness, and Hospital Indemnity Coverage • Fertility and Family Planning Support • Tuition Reimbursement and Certification Assistance • Continuing Education and Professional Development Resources • Employee Assistance Program and Wellness Support • Paid Time Off • Volunteer Time Off and Charitable Giving Match • Employee Referral Bonus Program